Friday, May 18, 2007

Midwife reality check

Although I do not deliver babies or perform prenatal care, many of my family physician colleagues do. Some even perform C-sections. You probably didn't know family docs could do all that, huh. Well, with malpractice premiums going up and payment/reimbursment going down, it's getting harder and harder to find any docs doing maternity care. Even some ob/gyn docs are dropping the ob (obstetrics/maternity care) part and doing more gyn (gynecology).

A story in today's Washington Post is outlining the reality of the medical economic environment for midwifes. Apparently, there are two huge birthing centers that are going to be closing in the Washington area. Seven other birth centers have closed their doors over the past decade.

"There are countless women scrambling to find out-of-hospital birth support," said Mary Beth Hastings, 39, a board member of the new Birth Options Alliance. The group, with about 300 members, will advocate "for a full range of birth options" in the Washington area...

Now, in my experience, most women I've talked with have no problem giving birth at the hospital with their midwife at their side. What's interesting about this article is that it highlights the small percentage of women who are anti-hospital, anti-doctor, pro-birthing center, and pro-midwife. Here is the reporter's bias coming out...

For a relatively small but devoted group of women, the idea of giving birth in a hospital with a physician connotes unwelcome images of being tethered to machines, talked out of natural childbirth or talked into a non-emergency Cesarean section.

A birth center, they say, provides a more relaxed, homelike environment without anesthesia or C-sections. Others say they want the option of an epidural for pain relief in a hospital but believe midwives will provide more personal support and be less likely than physicians to intervene with machines, surgery or medication.

Like I said above, I don't deliver babies nor do I perform C-sections. But, I'm definitely insulted by the statements above. These people want it both ways. Sure, treat my pain and/or if there is a problem - well then I'll see a doctor. Other than that, keep doctors away from me. Why is the perception that midwifes are "better?" Well, it's because they see the less complicated cases - thus the birthing experience may be seen as "easier."

Most midwives treat only healthy women with low-risk pregnancies. Anesthesia, such as an epidural block, and medications to speed up labor are available only in hospitals, and only physicians may perform C-sections.

Here we go. You saw this coming. Starting to make the case for "those bad doctors." It's the bad doctors who are driving the midwifes out of business. Yes, it's the doctor's fault. Here is more bias...

Those same [financial] pressures are felt throughout the health-care industry, but birth centers are particularly hard hit because they operate on slimmer profit margins than most physicians, midwives said. Several also cited problems unique to midwifery, including the growing popularity of C-sections, which they don't perform. Moreover, unlike obstetricians and gynecologists, midwives can't offset lower health insurance reimbursements for office visits with higher-paying surgeries.

This article is so politically motivated it makes me sick. The columnist wants you to think that there is a lack of access to maternity care in the Washington area and that physicians are to blame for this. With smoke and mirrors, it's subtily making the case that midwifes, in an effort to increase access to maternity care, should be given everything from C-section to epidural privileges.

And, oh by the way, doctors should decrease midwife malpractice premiums and increase payment/reimbursement to midwifes. Like physicians have any control over that. Want to make an impact in that, well do what everybody else does and go up to Capitol Hill and lobby Congress like the rest of us have to. Good luck with that.

For too long, physicians have always been the punching bag for the press - and I'm sick and tired of that. Physicians have been the target of every "health care provider" and the reason why physician's scope of practice has slowly been eroded away - especially in primary care. I'd better get off my soapbox now. Suffice to say, I didn't like this Post article and I hope people see through it for what it really is.

"These people want it both ways. Sure, treat my pain and/or if there is a problem - well then I'll see a doctor. Other than that, keep doctors away from me."

Yes, that's EXACTLY the point of midwifery. Childbirth is a natural,normal process that doesn't usually require intervention. A pregnant woman is not sick. That's what midwives are for - to assist women with a non-complicated pregnancy/labor. When there IS a medical problem, then a doctor is needed. Why can't women have it both ways?

From what I understand about midwifery, it emphasizes "natural" child birth - meaning no meds, no surgical intervention, etc.

I have no problem with that. If patients choose this route, then follow through with this philosophy - no meds, no surgical intervention, etc. In my opinion, it would be hypocritical not to.

If a patient has any doubt that they can carry through with the entire midwife experience (like no epidural), then they should decide the midwife experience is not for them, and then establish their maternity care with a physician. I think that would decrease the midwife/physician animosity.

Why are docs hated by some midwifes and patients - Because docs are called in for more complicated patient during labor/delivery. At this point, it's usually a highly emotional situation and the experience is not perceived as positive as it would be with a low risk midwife delivery. Anything that goes wrong is blamed on the doc.

Most midwifes I've worked with before definitely know their limitations. But, there is a subsegment of midwifes who believe they should have the same rights as docs. I believe this article brings this out.

I don't understand the whole midwife thing. I have had 2 children, under a doctor's care....why? Because I want the best for myself and my child. That way, if something does go wrong, my doc is there. I know him....and I won't have to worry about going from a midwife that I know to a doc I dont taking care of me. Because OB's go to med school, they have much more training and knowledge than a midwife. I wouldn't want a midwife who does NOT have the experience a doctor does having the same rights....that's what med school is for....and if they want the same rights, they should go there. I'm not trying to be mean of disrespectful in any way....I'm sure there are some very smart midwives out there....I'd just rather have a doctor working on me...just in case...cause you never know what might happen.

I have high praise for doctors and for midwifes. When I was pregnant with my second child, I decided that I wanted to see a midwife that had just moved to town. Unfortunately, I developed complications and I was transferred to the care of an excellent doctor. My midwife continued to follow my case and she was present during the delivery of my child. The doctor and the midwife worked together as a team. Their talents complimented each other, and made the delivery of my child a safe and happy event.

Here's a crazy thought. When I was pregnant, I chose my family physician of ten years to be my "OB" (she is also trained and highly experienced in obstetrics). I got flak from both kinds of people: the people who thought I really should choose an OB (I had a boringly uncomplicated pregnancy, by the way) and the people who thought I really should choose a midwife.

As a mom, you can't do anything right. I guess now they're adding doctors to that list?

"If a patient has any doubt that they can carry through with the entire midwife experience (like no epidural), then they should decide the midwife experience is not for them, and then establish their maternity care with a physician."

All or nothing, eh? I practice midwifery in an area where the relationships between all varieties of midwives and physician maternity service providers are very amicable. How can a woman possibly know what will occur in her labor and if she should want-- or need, yes sometimes they are necessary-- an epidural do you suggest I remind her she didn't sign up for a flexible birth plan?

As for what midwifery emphasizes, it is not on shunning modern medicine, technology, or consultation as many people erroneously assume. To practice as you suggest, all or nothing, would be dangerous.

Why choose a midwife? Because the literature clearly supports the safety of midwifery care for low- to moderate-risk women. Hell, even the safety of planned home births among low-risk women has been supported by the research.

The US is something of an anomaly in that we think we need a surgeon's skills to give birth safely. Our infant mortality stats, frankly, are in the toilet compared to other countries that use midwifery care much more extensively. Clearly, having surgeons deliver our babies hasn't done much but triple our c-section rate over the past 30 years.

I am very high-risk (Kell sensitized, hx of pre-eclampsia/HELLP, insulin-dependent gestational diabetes) and know that I am best managed by an OB, because I fall out of the range of normal. For a normal pregnancy, what is an OB going to do differently from a midwife?

As for Anonymous, who said she wanted a doc "because she wanted the best" and "in case anything went wrong", two thoughts: First, there are no guarantees in birth, regardless of who provides your care. Second, midwives are in the business of identifying when things do go wrong, and getting appropriate care for their patients.

Anon, it's true that docs have more training in obstetric procedures. The rights that I'm talking about that this subsegment are demanding are to be treated as equal as docs. They want to be trained/allowed to perform Procedures; They want the same Prescribing privileges as docs; and they want to be Paid the same as docs. Then why go to medical school and residency? Exactly. That's their point, in my opinion.

Frectis, If I unfairly stereotyped all midwives with respect to attitudes toward technology, it was not my intent to do that. I agree with you in that most of the midwifes I've worked with and have talked to are amicable. What concerns me is the subsegment of midwifes that are highlighted in this Post article. With regard to the rest of your comment, I would have to respectfully disagree. We'll have to agree to disagree on that one.

Meg, There have been many books, papers, and conferences discussing the reasons for the poor infant mortality in the US - and to point the finger solely at "surgeons" is unfair. Sure operative deliveries could be part of the reason, but everyone knows that there are a myriad of other factors involved. What's so interesting is that even with a poor infant mortality rate, people from around the world still have the attitude that the US is the best care in the world and come here for care. Imagine that.

"With regard to the rest of your comment, I would have to respectfully disagree. We'll have to agree to disagree on that one."

We should agree to disagree that woman should only employ a midwife if they can guarantee they will stay low risk, don't want an epidural or surgery? Well that's just impossible. That logic would put family practice doctors out of business because no one can guarantee they won't get sick and need a specialist or break something and need an ortho. Midwives are low man on the totem poll and should be seen as the first line, IMHO. If you need care greater than the scope they can provide, the referral is made. It works in every other facet of medicine, why not here? Obstetrics is very turfy.

"The rights that I'm talking about that this subsegment are demanding are to be treated as equal as docs. They want to be trained/allowed to perform Procedures; They want the same Prescribing privileges as docs; and they want to be Paid the same as docs. Then why go to medical school and residency? Exactly. That's their point, in my opinion."

I'm sorry to say it but this comment represents your ignorance about the scope of midwifery across the US and the politics involved. In all 50 states certified nurse-midwives are legal practitioners of obstetric care and depending on their additional education may provide high risk care as a solo provider or in collaboration with a physician (not all high risk is obstetrical in nature).

Many states have ruled them to be fully autonomous, including prescriptive authority on the schedule/classes for drugs pertaining to the scope of practice.

Regarding money: If the midwife has been trained and certified to do coloposcopies and biopsies for cervical cancer screening following abnormal paps, why shouldn't she be reimbursed the same? Many of those midwives you read in the article have hospital privileges and deliver their patient in the hospital at their request and in meeting patient demand they don't receive reimbursement for facility fee as they would if the woman gave birth there.

That article is not about midwives complaining they can't do cesareans. It's a complaint about the shift maternity care is making and how money is being lost because women are choosing high risk birth (elective cesareans for example) or not choosing birth centers.

Sometimes I find it surprising by how passionate some women/families are about avoiding medical intervention. I also read this article and although I didn't think it was terrific... I don't think my perception was the same as yours.In an earlier comment you wrote:"From what I understand about midwifery, it emphasizes "natural" child birth - meaning no meds, no surgical intervention, etc.I have no problem with that. If patients choose this route, then follow through with this philosophy - no meds, no surgical intervention, etc. In my opinion, it would be hypocritical not to."

I started to write a comment and found that I was taking up WAY to much space (apparently I had a lot to say) so instead I just posted about it... here is the link: http://nursechic.blogspot.com/2007/05/controversy-of-out-of-hospital-births.html

Frectis, I'm definitely an advocate for family medicine physicians and you're definitely an advocate for midwifery. And, there's nothing that we're going to say that's going to convince us otherwise. That's ok.

Turf wars in medicine have been going on forever in medicine. 30-40-50 years ago, I would say a majority of family medicine physicians were doing everything from obstetrics, to fracture care (orthopedics), to minor surgical procedures in the OR (appy). Many people don't know that about family medicine.

Then, the specialist movement started and was succesful, in my opinion. It successfully infiltrated into the American culture that you need a specialist and super-specialist for any ailment you have. The scope of practice for family medicine started to diminish and with it the professional reputation of family docs.

The enemies of family medicine call us "glorfied nurse practitioners, physicians assistants, and (yes) midwifes," because in some parts of the US, the FM scope of practice is very limited now. I very much take offense to that statement. Some have said that NP, PA, and midwives have reached medical legitmacy at the expense of family medicine losing favor in the American culture.

The fight for professional reputation and financial compensation will continue forever in medicine and you and I will be at the forefront of that for our colleagues. I hope that my FM advocacy is not interpreted as a personal attack against you or your profession. I continue to enjoy your blog (even though I don't comment that much) and will continue to enjoy your blog. I very much respect your point of view, and I hope you respect mine.

I view birth as a natural process. The less it's interfered with, the better. Unfortunately, because the c-section rate is going up, and because some practices aren't necessary within the OB scope of care, women are returning to their roots-having babies naturally. I don't feel that is a bad idea.

Perhapes midwives want to know how to do sections in case their patient runs into problems and needs to transport from home or a birthing center. I can understand the midwife not wanting to turn over thier patient to a stranger. I have read so many accounts of the bad treatment of transfers from hospital staff. I don't necessarily agree with the logic-I believe midwives should remain trained in the field of natural birth and let the OB's and surgeons handle the medical side.

Too bad midwives and OB's/doctors don't have a better relationship. In the end, it's the patient that suffers.

A common theme of many physician's blogs (e.g. Kevin MD, the late Dr. Flea) is that less intervention, less screening, less testing is better for patients (and for health care as a business).

However, the same philosophy doesn't seem to enter the OB/FP/Midwife debate. Many midwives (not all, and this is just my impression from reading midwives' blogs) promote a higher threshhold for performing tests during pregnancy: no *routine* internal exams, ultrasounds, glucose screens, etc.

So, is either approach--ACOG's recommendations for routine testing or midwifery's hands-off approach--better medicine? Is there room for subjective judgment by the patient?

And the debate rages on. I have gotten thrown, perhaps a little unwillingly into this debate when I got pregnant. As Dr. A said, some midwifes get along fine with doctors and they work hand-in hand. In some cases, it's like cats and dogs and there appears to be a turf war. Each with accusations, not always scientifically founded. Being a scientist who has to engage in research regularly myself, I have begun to wade through the mudslinging. Research has found death tolls of mothers and babies on both sides to be fairly equal. Occasionally a study comes up in favor of one or the other, but the difference is so slight it's hardly considered significantly different. There is ofcourse, a reduction of intervention at the hands of midwives, however, the people who choose this style birth will choose this type of care. I have not investigated studies that compare apples to apples on this subject. Though I am still investigating, it seems much of the debate can be narrowed down to quality and personality. I poor quality doctor or midwife is a bad choice. A good quality doctor or midwife, for a low-risk birth as a plan A is a good choice. Then, there's personality. If you can't see eye-to-eye with your care taker. It's abad choice. if you can, it's a good step in the right direction.

This is not based on personal experience, but reading medical journals, studies, and online articles. I happen to have a fair share of complaints about western medicine today. I've taken at least 3 prescriptions drugs/treatments that had more negative than positive effect in the last 11 years. It took alternative doctors/pacience on my part/research much less to actually "cure" the condition. I was also prescribed many treatments that had no noticeable effect. Perhaps I am a bit of a medical anomoly or perhaps, because I have moved about 10 times in the last 10 years, I have been given to the new or less desireable doctors. They would, after all, be more inclined to accept new patients. Regardless, I respect and believe those who have had excellent treatment from doctors and can't understand my "luck."

Again, my theory is it really just comes down to quality not type or quantity.